Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alta Vista Healthcare & Wellness Centre during CMS and state inspections, most recent first.
A resident with edema and pulmonary hypertension received Furosemide despite a physician's order to hold the medication if systolic blood pressure was below 110. An LVN administered the medication when the resident's blood pressure was 98/68, citing an undocumented verbal order. Review by the DON confirmed no documentation supported this deviation from the original order, and facility policy requiring adherence to medication parameters and documentation was not followed.
The facility failed to accurately code the MDS for PASRR Level II for four residents, despite having completed evaluations. Residents with mental health diagnoses, including psychosis, schizoaffective disorder, and PTSD, were not properly coded in the MDS, leading to discrepancies in their care plans. The DON and MDS staff were responsible for ensuring accurate coding, but a lack of access to the PASRR portal contributed to the errors.
A resident with a history of pneumonia and severe sepsis was readmitted with a peripheral IV access, but the facility failed to obtain physician's orders for its care, including flushes and dressing changes. The IV site was not assessed or documented as per facility policy, and the dressing was left unchanged for over 20 days. Interviews with staff revealed a lack of clarity and adherence to IV care protocols, resulting in a deficiency in the standard of care provided.
Two residents with muscle wasting and cognitive impairments were not provided with splints as ordered, leading to deficiencies in their care. Despite physician orders for daily application of splints to prevent contractures, observations revealed the absence of splints, and documentation was lacking. Staff interviews confirmed the failure to apply splints consistently, highlighting a breakdown in the facility's restorative nursing program.
A facility failed to limit a PRN psychotropic medication order for a resident to 14 days, as required by policy, affecting a resident with schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, and unspecified dementia. The resident's Ativan order lacked a stop date and documented rationale for continued use. Staff interviews revealed a lack of adherence to policy, with no reassessment conducted to determine the ongoing need for the medication.
A facility failed to disinfect a glucometer between uses, leading to potential infection risks. An LVN used the same glucometer on two residents without cleaning it, contrary to CDC guidelines and facility policy. Staff interviews confirmed the requirement for disinfection with EPA-approved wipes before and after each use.
Failure to Follow Physician's Order for Medication Administration Based on Blood Pressure Parameters
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow a physician's order regarding the administration of Furosemide for a resident with localized edema and pulmonary hypertension. The physician's order specified that Furosemide should be held if the resident's systolic blood pressure (SBP) was less than 110. Despite this, the medication was administered on a day when the resident's blood pressure was recorded as 98/68, which was below the prescribed threshold. During interviews and record reviews, the nurse stated that a verbal order had been given by the physician to continue the medication despite the low SBP, but there was no documentation in the resident's medical record or progress notes to support this claim. The Director of Nursing confirmed that there was no documentation authorizing the administration of Furosemide outside the original parameters. Facility policy required that medications be administered as prescribed and that vital signs be checked and documented when administration is dependent on such parameters, which was not followed in this instance.
Inaccurate MDS Coding for PASRR Level II
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for four residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not have a policy on MDS accuracy and relied on the Resident Assessment Instrument (RAI) manual. The Director of Nursing (DON) acknowledged the absence of a specific policy and stated that the MDS coordinators were responsible for coding section A of the MDS, which includes PASRR Level II information. Resident #14 was admitted with a history of unspecified psychosis and vascular dementia. Despite having a PASRR Level II evaluation completed, the MDS did not reflect this, indicating a failure to accurately code the resident's mental health needs. Similarly, Resident #62, with diagnoses including schizoaffective disorder and bipolar disorder, had a PASRR Level II evaluation, but the MDS did not reflect this. The Social Services Supervisor confirmed the residents were receiving psychiatric services, yet the MDS staff failed to accurately code the necessary information. Resident #80, with diagnoses of anxiety disorder and PTSD, also had a PASRR Level II evaluation, but the MDS did not reflect this. The resident refused psychiatric services, preferring family support, yet the MDS was inaccurately coded. Resident #55, with severe cognitive impairment and multiple mental health diagnoses, had a positive Level I PASRR screening, but the MDS did not reflect the Level II evaluation. Interviews with the DON and MDS Coordinator revealed a lack of access to the PASRR portal until recently, contributing to the inaccuracies in MDS coding.
Failure to Provide and Document IV Site Care
Penalty
Summary
The facility failed to provide and document care for a peripheral intravenous (IV) access site in accordance with accepted nursing standards and facility policy for a resident. The resident, who was readmitted to the facility with a medical history of pneumonia and severe sepsis with septic shock, had a peripheral IV access in the right foot. However, there were no physician's orders for the care or maintenance of the IV site, including flushes or dressing changes. The dressing on the IV site was observed to be over 20 days old, and the resident's care plan did not address the presence of the IV access site or include interventions for its care and monitoring. Interviews with facility staff revealed a lack of clarity and adherence to the facility's policy regarding IV site care. The RN Supervisor stated that the IV access was discontinued only after confirming it was not needed, but there was no documentation or orders for its care prior to removal. LVN #7 and LVN #5 indicated that the site should have been assessed and monitored every shift, with appropriate orders for flushing and dressing changes, but this was not done. The Director of Staff Development and the Director of Nursing also expressed uncertainty about the frequency of dressing changes and the duration a peripheral IV line could remain in place. The Administrator acknowledged that if a resident was admitted with IV access, the nurse should determine its necessity and obtain physician orders for its care. Despite this, the facility did not have such orders for the resident in question, leading to a deficiency in the standard of care provided. The lack of proper documentation and adherence to facility policy resulted in the IV site remaining in place without necessary care or monitoring, highlighting a significant oversight in the facility's care processes.
Failure to Apply Splints as Ordered for Residents
Penalty
Summary
The facility failed to ensure that splints were applied as ordered for two residents, leading to deficiencies in their care. Resident #18, who had a medical history of muscle wasting, atrophy, and cachexia, was observed without the necessary splints on multiple occasions. Despite having orders for a right elbow extension splint and a right resting comfy hand splint to be applied daily, these were not consistently applied, and there was a lack of documentation for the splint care on several days. Interviews with staff revealed that the splints were not applied regularly, and there was no documentation explaining the absence of the splints. Similarly, Resident #46, who had severe cognitive impairment and functional limitations in range of motion, was also observed without the required splints. The resident had orders for left and right elbow extension splints to be applied daily, but these were not consistently in place, and documentation was missing for several days. Staff interviews indicated that the splints were not applied as ordered, and there was no documentation to justify the lack of application. The facility's staff, including RNAs, LVNs, and the Director of Nursing, acknowledged the importance of splints for contracture prevention and the need for adherence to physician orders. However, there was a clear breakdown in the implementation and documentation of the restorative nursing program, leading to the observed deficiencies in care for both residents.
Failure to Limit PRN Psychotropic Medication Order to 14 Days
Penalty
Summary
The facility failed to ensure that an as-needed (PRN) psychotropic medication order for a resident was limited to 14 days unless there was documented rationale for extended use and a specific duration of the order. This deficiency affected a resident with a medical history of schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, and unspecified dementia. The resident had a PRN order for Ativan, a benzodiazepine, with no stop date or documented rationale for continued use. The facility's policy required that any psychoactive medication ordered on a PRN basis must not exceed 14 days unless the physician documented the reasons for continued usage. Interviews with facility staff, including a Registered Nurse, Licensed Vocational Nurse, Director of Staff Development, Director of Nursing, and the Administrator, revealed a lack of adherence to the facility's policy regarding PRN psychotropic medications. The staff acknowledged that the PRN order should have had a 14-day stop date and that the resident should have been reassessed to determine the ongoing need for the medication. However, the resident's Ativan order did not have a stop date, and there was no documentation of reassessment for the rationale of its ongoing use. The Director of Nursing confirmed that the resident exhibited behaviors warranting the use of the medication, but the necessary procedural steps were not followed, leading to the deficiency.
Failure to Disinfect Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a glucometer between uses, which is crucial to prevent the potential spread of infection. Observations revealed that a Licensed Vocational Nurse (LVN) performed blood glucose tests on two residents without cleaning or disinfecting the glucometer between uses. After testing Resident #7, the LVN placed the uncleaned glucometer on the medication cart and proceeded to use the same device on Resident #26 without disinfection. This action was contrary to the facility's policy and the Centers for Disease Control and Prevention (CDC) recommendations, which require cleaning and disinfection of reusable medical equipment between residents. Interviews with various staff members, including the Infection Preventionist, Registered Nurse Supervisor, Director of Staff Development, Director of Nursing, and the Administrator, confirmed that the glucometer should be cleaned before and after each use with an Environmental Protection Agency (EPA)-approved disinfectant. The LVN involved admitted to forgetting to disinfect the glucometer due to nervousness. The facility's policy, revised in 2012, clearly states that reusable items must be cleaned and disinfected or sterilized between residents, aligning with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Health Care Center | 0.2 mi | — | 1 | 0 |
| Mission Care Center | 0.6 mi | — | 1 | 0 |
| Riverwalk Post Acute | 0.8 mi | — | 21 | 0 |
| Citrus Grove Post Acute | 0.9 mi | — | 18 | 0 |
| Extended Care Hospital Of Riverside | 1.2 mi | — | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.